New Client Form Name(Required) First Last Spouse's Name … if no spouse please put n/a(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Cell Phone(Required)Other PhoneTexting Capabilities(Required) Yes No Email(Required) How did you hear about our clinic?(Required)Drive ByGoogleFacebookYelpOther online sourcePrevious ClientRescue OrganizationOtherWhom may we thank?(Required) First Last Please read our final policy very carefully prior to signing it. Our policy is to provide you with a written estimate of fees that are required for in-clinic treatment, emergency care, surgery, and/or hospitalization. A deposit is required prior to any treatment and for all hospitalized animals. Hospital accounts must be kept current throughout the period of hospitalization. If you do not pick up your pet within 10(ten) days of its release date, your pet will be considered abandoned. Your total bill, which is to include the treatment charges plus ten additional days of hospitalization, will be turned over to a national collection bureau, to be placed on your credit record.Please indicate your preferred form of payment(Required) Cash Visa/MC Discover Amex Care Credit Scratchpay Patient InformationPet Name(Required) Type of Pet(Required) Dog Cat Breed(Required) Birthday(Required) MM slash DD slash YYYY Age(Required) Color/Description(Required) Sex of Pet(Required) Male Unaltered Female Unaltered Male Neutered Female Spayed Microchip number if available…if none please put N/A(Required) Add another pet?(Required) Yes No Pet Name(Required) Type of Pet(Required) Dog Cat Breed(Required) Birthday(Required) MM slash DD slash YYYY Age(Required) Color/Description(Required) Sex of Pet(Required) Male Unaltered Female Unaltered Male Neutered Female Spayed Microchip number if available…if none please put N/A(Required) Add a third pet?(Required) Yes No Pet Name(Required) Type of Pet(Required) Dog Cat Breed(Required) Birthday(Required) MM slash DD slash YYYY Age(Required) Color/Description(Required) Sex of Pet(Required) Male Unaltered Female Unaltered Male Neutered Female Spayed Microchip number if available…if none please put N/A(Required) Do you have insurance for your pet/s?(Required) Yes No Previous Illnesses or Surgeries(Required)Current Medications and/or Special Diets(Required)I have read and understand the above policies and request treatment for my pet(s) in accordance with these policies. I assume all financial responsibilities for all charges incurred to the patient(pet), and agree to pay all costs of collection and/or fees in the event of non-payment. To prevent the spread of infectious diseases and parasites, hospitalized or boarded pets must be current on all vaccines and be free of internal and external parasites. I authorize Gulf Coast Veterinary Center to administer vaccines and/or parasite control when needed, and understand that I will be responsible for paying any associated charges.(Required)Sign hereDate(Required) MM slash DD slash YYYY CAPTCHA Δ
